Please help us to improve the services at Clifford Beers Clinic by answering a few questions about your experiences with the clinic. Your answers are confidential and will not influence the current and/or future services your child receives at Clifford Beers.

What is the name of the Family Advocate or Clinician you are working with?

Your answer

Date

MM

/

DD

/

YYYY

1. I have been able to get the services my child needs?

Yes

No

2. I have been able to get the services I need?

No

Yes

3. I have received information on how to keep me/my family safe?

Yes

No

4. I know how to plan for & take action to keep me safe?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

N/A

5. I know how to plan for & take action to keep my child(ren) safe?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

N/A

6. I received information of my rights within the criminal justice system for domestic violence and sexual abuse?

Yes

No

N/A

7. I have increased my understanding of the criminal justice system for domestic violence and sexual abuse?

Yes

No

N/A

8. I received information (I.E. verbal confirmation, pamphlet) about the Connecticut Victim Services Compensation Program through the Office of Victim Services?